1. HYSTEROSCOPY FOR INFERTILE PATIENT An Evidence Based Approach Dr.Mohamed El Sherbiny MD Obstetrics&Gynecology Senior Consultant Damietta General Hospital Damietta Egypt

2. oCochrane library. oRoyal College of Obstetricians &Gynecologists (RCOG) Guidelines. oJournal of evidence based obstetrics and gynecology. oNational Guideline Clearinghouse. oNew Zealand Guidelines Group oPubMed Sources of EB for The Topic

3. DIAGNOSTIC HYSTEROSCOPY

4. RIGIDE OR FLEXIBLE ?? A rigid hysteroscope was superior to a flexible hysteroscope for outpatient hysteroscopy Rudi Campo, Evidence-based Obstetrics & Gynecology Volume:3 Issue:3 Date:September 2001 p140-141

5. Preparation of The Cervix Vaginal misoprostol prior to diagnostic hysteroscopy reduced cervical resistance in non-pregnant women Fong& Singh Evidence-based Obstetrics & Gynecology : 3 Issue:2 Date:June 2001 p88-90

6. Distension Media: Saline Vs Co 2 Normal saline should be used as it offers: advantages (shorter and less discomfort) over co 2 instillation. New Zealand Guidelines Group : Level A

7. SHOULD HYSTERSCOPY BE DONE ROUTINLY IN THE EVALUATION OF INFERTILITY ? NO

8. Tests which have an established correlation with pregnancy are: 1- Semen analysis 2-Tubal patency by HSG or laparoscopy 3-Mid luteal progesterone for the diagnosis of ovulation They are the basic essential tests for diagnosis of infertility. ESHRE Capri workshop & Routine Infertility Investigation National Guideline Clearinghouse 2000 RCOG Guidelines : Grade B Recommendation 1999

9. Routine Infertility investigation??! Hysteroscopy should not be considered as a routine investigation in the infertile couple. RCOG Guidelines : Grade C Recommendation 1999

10. Indications of Diagnostic Hysteroscopy for Reproductive Failure Abnormal hysterosalpingogram. Abnormal uterine bleeding Suspected intrauterine pathology Uterine anomalies Pregnancy wastage Unexplained infertility Valle 1996

11. When Hysteroscopy Should Be Done For Unexplained Infertility ? At Laparoscopy ? Before IVF ? After Failed IVF ?

12. SHOULD HYSTEROSCOPY BE USED ROUTINELY AT THE TIME OF LAPAROSCOPY FOR. THE INVESTIGATION OF. INFERTILIY ?

13. El Sherbiny M, Medical J of Cairo Univ., Vol.65 No. 3, Sept. 1997 El Sherbiny M, The 7th Annual Meeting Of The Intern. Society for Gynecologic Endoscopy,Sun City, South Africa;15:18 March,1998 Hysteroscopy done at laparoscopy time, has low complication rate, high degree of safety, minimal time requirement and adds little equipment & cost. Positive hysteroscopic findings were found in many cases (15%) despite having normal HSG and no suggestive history of uterine lesion

14. Unexplained infertility Small endometrial polyp Small cervical polyp Adhesion at cornual cones Cornual polyp Endometrial dystrophies (atrophy or hyperplasia) that may affect receptivity or implantation especially in ART.

15. Unexplained infertility ` Cornual polyp cervical polyp HSG is free

16. Mini-pan-endoscopic Approach Transvaginal hydrolaparoscopy in association with Minihysteroscopy provided more information and was better tolerated than HSG in an outpatient infertility investigation. Cicinelli et al. Fertil Steril 2001 Nov;76(5):1048-51 RCT (23 cases)

17. OPERATIVE HYSTEROSCOPY

18. Indications of Operative Hysteroscopy for Reproductive Failure Polyp. Submucous leiomyoma. Uterine septa. Intrauterine Adhesions. Misplaced or embedded IUD Tubal cannulation & Falloposcopy. Valle 1996

19. Priming With Misoprostol Vaginal misoprostol prior to operative hysteroscopy facilitated the procedure and reduced complication Y.F.Fong and K.Singh Evidence-based Obstet & Gynecol.,2000

20. Uterine Polyp Uterine Fibroid

21. Both saline infusion sonohysterography and hysteroscopy are well tolerated by women. Saline infusion sonohysterography has a high failure rate but has a lower pain score than hysteroscopy. Rogerson et al, BJOG 2002 Jul;109(7):800-4 RCT (117 cases) Transvaginal Sonohysterography Versus Hysteroscopy

22. (TVSH) should be considered prior to hysteroscopy in women in whom intrauterine pathology such as submucous fibroids and polyps are suspected as diagnostic hysteroscopy can be avoided in up to 40% of women New Zealand Guidelines Group : 1998-2002 Level A

23. 3638 Uterine Polyp Sonohysterography Hysteroscopy

24. Electro- resection of myoma by loop electrode loop electrode Fibroid Resected tissue

25. Uterine Fibroid Women who are diagnosed with submucous uterine fibroids and heavy or abnormal menstrual bleeding should be offered hysteroscopic resection. New Zealand Guidelines Group : 1998-2002 Level C

26. Myomas can be removed effectively when:  Uterine size (depth )8-12 cm  >50% inside cavity.  < 5 Cm size Hysteroscopic Resection Advanced Reproductive Care Inc : 2002

27. Endometrial Thinning Prior To Hysteroscopic Surgery For Menorrhagia It improves both the operating conditions for the surgeon and short term post-operative outcome. GRH analogues produce slightly more consistent endometrial thinning than danazol. Sowter et al : 1998 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.

28. Intrauterine synechiae

29. HSG : Filling defect Stellate & irregular, Commonly inhomogeneous HYSTEROSCOPY Confirmation Evaluation of the extent of the disease Intrauterine Synechiae

30. The American Fertility Society classification of intrauterine adhesions.1988. Extent of 2/3 Cavity Involved 1 2 4 Type of Filmy filmy & Dense Dense Adhesions 1 2 4 Menstrual Normal Hypomenorrhea Amenorrhea Pattern 0 2 4 Stage I (Mild) 1 - 4 Stage II (Moderate 5 - 8 Stage III (Severe) 9 - 12 Combined HSG & hysteroscopy & clinical

31. Intrauterine Synechiae Severe Moderate

32. It is controversial whether patients should:  Receive prophylactic antibiotics ?  Receive postoperative estrogen ?  Use of an IUD or Foley catheter ? Advanced Reproductive Care Inc : 2002 Intrauterine Synechiae: Postoperative Treatment

33. Division of the adhesions with: The endoscope The curettes or scissors. Resectoscopic cautery. Neodymium-YAG laser Advanced Reproductive Care Inc : 2002 121 Intrauterine Synechiae: Operative Treatment

34. Restoration of menses: 70- 90% Pregnancy rate : 60% - 90%. Term pregnancy : 40- 80% Poor for : Severe disease, Multiple procedures have been necessary. Intrauterine Synechiae : Prognosis Advanced Reproductive Care Inc : 2002

35. Perforation : 2%. Infection : 2%. Adhesion reformation :20-40%. Placental complications :2-40%.. Intrauterine Synechiae : Complications Advanced Reproductive Care Inc : 2002

36. CONGENITAL ANOMALIES

37. Septate Uterus : Value of Hysteroscopy Confirming the abnormality Evaluating the uterine cavity capacity Discarding other pathologic findings such as polyps, endometritis, hypertrophy Guiding surgical aproach Traver et al. Infertility in the 3 rd Millennium Prague, 2000

38. Resection of the Uterine Septum 121 Laparoscopic Guided Septum Collin's Electrode

39. Abdominal Vs Hysteroscopic Resection of The Septum Hysterscopic resection is preferable based on: Cost Morbidity Anatomical outcome Reproductive oucome Faize, Obstet.gynecol 68:399, 1986

40. Proximal Tubal Obstruction (PTO)

41. Proximal Tubal Obstruction  Fibrosis obliteration&SIN 40%  Endometriosis & Cornual polyp 10%  Cornual spasm 20%  Amorphous material 50%  Viscous secretions 30%  Mucosal agglutination  Stromal edema Valle 1996

42. Oil-soluble Versus Water-soluble Media for Hysterosalpingography Flushing of the tubes with oil-soluble media increases subsequent pregnancy rates in infertility patients. It may flush tubal "plugs" that are a cause of proximal tubal occlusion. Clinicians should consider flushing the tubes with OSCM before contemplating more invasive therapies. Vandekerckhove et al., July 1996 (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.

43. Tubal Catheterization Where proximal tubal obstruction is suspected, and there are no other tubal abnormalities, a tubal catheterisation procedure may be attempted RCOG Guidelines : Grade B Recommendation

44. Tubal Catheterization Bilateral Cornual Block Amorphous material R. Ovary R. fimbria Cornual catheterization

45. Falloposcope Recently, the Food and Drug Administration has just given the first approval for a falloposcope in the United States. The falloposcope will be utilized through the hysteroscope and will allows direct visualisation of the proximal segment and provides an atraumatic recanalisation.. Advanced Reproductive Care Inc : 2002

46. The risk to normal fallopian tubes through the use of falloposcopy is not clearly known but thought not to be significant.. Falloposcope Advanced Reproductive Care Inc : 2002

47. Thank You